Psychosomatic group treatment helps women with chronic pelvic pain

Albert, H. (1999). Journal of Psychosomatic Obstetrics and Gynaecology, 20(4), 216-225.
Reviewed by Brittany Burton, doctoral physical therapy candidate from the University of Minnesota, 2014. 
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Background: In this study, group treatment for women with chronic pelvic pain based on physical, psychosomatic and behavioral therapeutic principles of treatment was assessed. Significant reduction in average pain intensity, use of medications, pelvic surgeries was noted, as well as an improved work status among women in the study.
Introduction: Background is given regarding how women with chronic pelvic pain often have both physical and psychological pain.  It is noted in this section that studies show that women with pelvic pain have common characteristics such as being a fertile age, have had some traumatic experience, and often are depressed. Studies have also shown that behavioral therapy or group therapy with physical exercise treatment is effective for patients with pain. 
Goals of study: To evaluate group treatment of women with chronic pelvic pain based on physical, psychosomatic and behavioral therapeutic principles of treatment.
Subjects: Cohort study which functions as its own control.  The women were referred to the physiotherapy department from the gynecological ward or the outpatient clinic.  Inclusion criteria: woman must have suffered from pelvic pain for more than 6 months, been thoroughly examined and treated for any gynecological diseases, and examined by physiotherapist who decided woman was suited for group physical therapy. Exclusion criteria were any previous or current cancer, any psychiatric disorders and illiteracy or reduced intelligence. 64 women started the treatment, 7 dropped out after first or second treatment and four stopped halfway through. 53 women completed the treatment with an average age of 30.5 years old ranging from 18-48. Average period of pain was 5 years and 9 months before the treatment. Further demographics listed in paper.
Methods: 10 total weekly treatments of 2.5 hours were given to all women. The first hour consisted of physical activities designed to the needs of the group including strength and conditioning, specific exercises of the pelvis and pelvic floor, self-relaxation, visualization, exercises to let go of aggression, exercises of confidence grounding exercises and body massage. The second 1.5 hours were for therapeutic group conversation.  Between group treatment the subjects were given homework to describe themselves in 3 sentences, do something pleasant for themselves or to name 3 parts of body they are satisfied with.  Each subject completed outcome measures at baseline, at the last group treatment, 3 months and 1 year after end of treatment. During every 7 day period, the following were recorded once every hour when awake: level of pain on VAS, intake of drugs, time spent sitting, standing and lying and state of mood. Average for each woman was calculated. A qualitative analysis of the data was done using the grounded theory (coding). A percentage calculation of the qualitative data was made and results were compared to baseline via the McNemar test and t-tests. Methodological triangulation was also used.
Results: Quantitative results-Significant reduction in pain between baseline and follow up for average pain intensity (VAS). Intake of analgesics was reduced from an average of 8.5 units per week to .9, which is also a significant change.  Of note as well are the milder types of medications taken. At baseline, all 53 women had been hospitalized for at least one treatment on the gynecological ward.  Average number of admissions to the hospital  was 3.7 times; average pain duration 5 years and 9 months, 67% of women had had a laparoscopy, and 57% had undergone major operation. At y year follow up, only 3 women had been admitted for treatment on gynecological ward, none of the women had had a laparoscopy since and three women had a major pelvic operation. Nine women who were on sick leave got a job or began an educational path, some women changed jobs to better ones (even management), and 8.5% were unemployed which is lower than women of this age group who primarily belonged to the lowest social class. Qualitative results- Women were asked whether group treatment had changed anything in their ways of communication, their perception of pain, their ways of reaction and priorities in life.  56 substantive codes found were covered by 4 categories: self-knowledge (acquiring knowledge of her reactions, patterns of conduct, body language and desires), self-responsibility (for getting needs and wishes fulfilled and for her own physical and psychological actions), self-activeness (acts to get wished and needs fulfilled and to control her body, surroundings and role in the family and in the society) and self-control (control of verbal and physical expressions so that they correspond with the situation). The pain drawings changed shape, becoming more diffuse, color from fierce black and red to dotted black, yellow or light red, and size over the treatment, smaller.  For further explanation see discussion section in paper.
Limitations: Study has a selection bias as mild pain patients are not going to the hospital for treatment, there were some dropouts, which may have been the most severely injured women psychologically and selected themselves out of the treatment, factors causing pelvic pain are likely multiple, and the study  was not a clinically controlled study. Results may also apply to different trauma and patients with other chronic pain.
Conclusion: By means of group treatment based on principles of psychosomatic treatment as well as an operant and cognitive behavioral therapy it is possible to reduce the pain intensity experienced by women with chronic pelvic pain, reduce number of admissions to hospitals, reduce operations and improve working status. 


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